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The Association of Preoperative Malnutrition with Delayed Wound Healing and Related Postoperative Complications: A Systematic Review Pretika Prameswari; Raka Jati Prasetya; Mutia Juliana
The Indonesian Journal of General Medicine Vol. 19 No. 2 (2025): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/jpfdb756

Introduction: Preoperative malnutrition is a prevalent and modifiable risk factor in surgical patients, yet its full impact on postoperative recovery remains a critical area of clinical investigation. The objective of this systematic review is to comprehensively synthesize the existing evidence linking preoperative malnutrition to delayed wound healing and a broad spectrum of other adverse postoperative outcomes. Methods: A systematic search of the PubMed, EMBASE, and Cochrane Library databases was conducted to identify relevant observational studies and meta-analyses. Studies were selected if they investigated the association between a defined measure of preoperative malnutrition and postoperative outcomes in adult surgical patients. The methodological quality and risk of bias of included studies were rigorously assessed using the Cochrane "Risk Of Bias In Non-randomized Studies - of Interventions" (ROBINS-I) tool. Data were extracted for a minimum of 15 distinct outcomes, with a primary focus on wound healing complications. Results: Twenty-five studies, encompassing a wide range of surgical specialties and patient populations, met the inclusion criteria. The analysis revealed a consistent and statistically significant association between various markers of malnutrition—including hypoalbuminemia, low Prognostic Nutritional Index (PNI), and high Nutritional Risk Screening 2002 (NRS-2002) scores—and adverse postoperative events. Malnourished patients demonstrated significantly increased rates of surgical site infections (Odds Ratio range: 1.97 to 4.12), wound dehiscence (OR up to 3.24), and anastomotic leakage. Furthermore, malnutrition was strongly correlated with prolonged length of hospital stay (mean difference up to 5.58 days), increased 30-day mortality (OR up to 3.61), higher readmission rates, and a greater incidence of systemic complications such as pulmonary, cardiac, and renal events. Discussion: The synthesized evidence underscores the systemic impact of malnutrition on the physiological response to surgical stress and subsequent recovery. The findings suggest that nutritional deficiencies impair fundamental biological processes, including immune function and tissue synthesis, which are critical for uncomplicated wound healing. The clinical implications are significant, highlighting the necessity of integrating nutritional screening into routine preoperative assessment to identify at-risk patients who may benefit from targeted nutritional optimization. Conclusion: Preoperative malnutrition is a robust and independent predictor of delayed wound healing and a wide array of associated postoperative complications. The integration of routine nutritional assessment and appropriate intervention into standard preoperative care pathways is strongly recommended to improve surgical outcomes, reduce healthcare utilization, and enhance patient safety.

A Systematic Review of the Association of Preoperative Optimization of Diabetic Patients with Perioperative Glycemic Control and Postoperative Outcomes Pretika Prameswari; Raka Jati Prasetya; Mutia Juliana
The International Journal of Medical Science and Health Research Vol. 20 No. 3 (2025): The International Journal of Medical Science and Health Research
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/ptswat97

Introduction: The prevalence of diabetes mellitus (DM) in surgical populations is substantial and represents a significant independent risk factor for postoperative complications. Preoperative optimization of glycemic control has emerged as a key strategy to mitigate these risks by improving patients' physiological resilience to surgical stress. This review systematically evaluates the association between preoperative glycemic status and postoperative outcomes. Methods: A systematic search of PubMed and the Cochrane Library was conducted for studies published through 2024. Inclusion criteria specified randomized controlled trials and observational studies evaluating preoperative glycemic markers (e.g., glycated hemoglobin ( HbA1c ), blood glucose) or structured optimization interventions in adult diabetic patients undergoing surgery. Primary outcomes included surgical site infection (SSI), 30-day mortality, and major adverse cardiovascular events (MACE). Secondary outcomes included length of stay (LOS), acute kidney injury (AKI), and other morbidities. Study quality was appraised using the Cochrane Risk of Bias 2 and ROBINS-I tools. Results: Seventeen studies, encompassing randomized trials and large cohort analyses, met the inclusion criteria. The evidence consistently links poor preoperative glycemic control, indicated by elevated HbA1c or acute hyperglycemia, with a significantly increased risk of postoperative complications. Specifically, high HbA1c levels were strongly associated with higher rates of SSI (Odds Ratio ranging from 2.13 to 3.0) and prolonged hospital LOS. Acute perioperative hyperglycemia was a more direct predictor of MACE and mortality (Hazard Ratio 1.26 for adverse cardiac events). Structured interventions, such as multidisciplinary preoperative clinics, demonstrated efficacy in reducing preoperative HbA1c levels, particularly in patients with the poorest baseline control. Discussion: The synthesized evidence highlights a critical debate regarding the predictive primacy of chronic ( HbA1c ) versus acute (perioperative blood glucose) hyperglycemia. While acute hyperglycemia appears to be the more proximate driver for immediate adverse events like myocardial injury, HbA1c serves as an essential tool for risk stratification, identifying patients who will benefit most from intensive perioperative management. The heterogeneity of the existing literature, particularly the scarcity of high-quality randomized trials, underscores the complexity of this issue. Conclusion: Poor preoperative glycemic control is unequivocally associated with adverse postoperative outcomes in diabetic patients. While the optimal strategy for preoperative optimization remains to be defined by high-quality evidence, current data support a shift from using HbA1c as a rigid surgical gatekeeper to a trigger for activating comprehensive, multidisciplinary perioperative management pathways.

Association of Deep versus Moderate Neuromuscular Blockade with Surgical Conditions and Postoperative Pulmonary Complications: A Systematic Review of Randomized Controlled Trials Pretika Prameswari; Raka Jati Prasetya; Mutia Juliana
The International Journal of Medical Science and Health Research Vol. 20 No. 3 (2025): The International Journal of Medical Science and Health Research
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/b7aatk91

Introduction: The optimal depth of intraoperative neuromuscular blockade (NMB) remains a subject of clinical debate. Deep NMB is hypothesized to improve surgical conditions, particularly in minimally invasive surgery, but has historically been associated with an increased risk of postoperative pulmonary complications (PPCs) due to residual neuromuscular blockade (rNMB). This systematic review evaluates the evidence from randomized controlled trials (RCTs) to compare the effects of deep versus moderate NMB on surgical conditions and the incidence of PPCs. Methods: A systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials was conducted to identify RCTs comparing deep NMB (defined as a post-tetanic count of 1-2) with moderate NMB (defined as a train-of-four count of 1-2) in adult surgical patients. Primary outcomes were measures of surgical conditions (e.g., surgical rating scales, intraoperative patient movement) and the incidence of a composite of PPCs (e.g., pneumonia, atelectasis, respiratory failure). Secondary outcomes included postoperative pain, opioid consumption, recovery times, and other adverse events. Methodological quality was assessed using the Cochrane Risk of Bias 2 tool. Results: Seventeen RCTs met the inclusion criteria. The evidence consistently demonstrated that deep NMB was significantly associated with improved surgical conditions, including higher surgeon-rated scores, a significantly lower incidence of intraoperative patient movement, and the facilitation of lower intra-abdominal pressures during laparoscopy. Regarding safety, when deep NMB was managed with quantitative neuromuscular monitoring and reversed with appropriate agents, particularly sugammadex, there was no statistically significant increase in the incidence of composite PPCs, pneumonia, or atelectasis compared to moderate NMB. Furthermore, deep NMB was significantly associated with beneficial secondary outcomes, including reduced postoperative pain scores, lower opioid consumption, and a decreased incidence of postoperative nausea and vomiting. Discussion: The findings suggest a clear dissociation between the intraoperative depth of NMB and postoperative pulmonary risk. The primary driver of PPCs is postoperative rNMB, a risk that can be effectively mitigated with precise neuromuscular monitoring and the use of reversal agents capable of reliably antagonizing deep block. The benefits of deep NMB on surgical quality are substantial and are complemented by improvements in postoperative pain and recovery metrics. Conclusion: Deep NMB provides significant intraoperative advantages over moderate NMB, enhancing surgical conditions and safety. When implemented as part of a comprehensive strategy that includes quantitative monitoring and effective pharmacological reversal to prevent residual paralysis, it is not associated with an increased risk of postoperative pulmonary complications and may improve aspects of postoperative recovery.

The Comprehensive Systematic Review of Vasoactive-Inotropic Score as a Predictor of Outcome in Pediatric Critical Care Mohamad Fadli; Raka Jati Prasetya; Mutia Juliana
The Indonesian Journal of General Medicine Vol. 30 No. 1 (2026): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/29yj3207

Introduction: The Vasoactive-Inotropic Score (VIS) quantifies cardiovascular support in critically ill children by aggregating vasoactive medication doses into a single numerical value. Despite widespread clinical use, a comprehensive synthesis of VIS as a predictor of pediatric outcomes across diverse populations is lacking. This systematic review aimed to evaluate the predictive value of VIS for mortality and morbidity in pediatric critical care populations. Methods: A systematic review was conducted following PRISMA guidelines. We screened studies based on predefined criteria: pediatric population (0-18 years), explicit VIS calculation using standard formulas, reporting of clinical outcomes, and statistical analysis examining VIS-outcome relationships. Studies were excluded if limited to adult populations, case reports, conference abstracts, or editorials. Data extraction included population characteristics, VIS calculation methods, predicted outcomes, predictive performance metrics, and key findings. Results: Eighty-seven studies published between 2010-2025 met inclusion criteria, encompassing 29,920 patients across diverse settings (PICU, cardiac ICU, NICU). Post-cardiac surgery populations were most frequently studied (n=34), followed by septic shock (n=18) and neonatal populations (n=15). VIS demonstrated strong mortality prediction across populations: septic shock (AUROC 0.779-0.976), neonatal cardiac surgery (AUROC 0.83), congenital diaphragmatic hernia (AUROC 0.925), and extremely low birth weight preterm infants (AUROC 0.816-0.92). Optimal thresholds varied substantially from VIS >5 in preterm infants to >70 in myocarditis. Maximum VIS in the first 24-48 hours showed strongest associations with outcomes. VIS predicted prolonged mechanical ventilation (OR 5.20, 95% CI 3.78-7.16) and composite poor outcomes (OR 6.5-8.1). The Vasoactive-Ventilation-Renal (VVR) score outperformed VIS alone in cardiac surgery populations (AUC 0.87-0.98 versus 0.68-0.78). Discussion: VIS demonstrates consistent predictive validity across pediatric critical care populations, with performance comparable or superior to established scoring systems. Threshold heterogeneity reflects population-specific severity, age-related physiologic differences, and condition-specific considerations. Serial VIS monitoring provides incremental prognostic information beyond single measurements. Conclusion: VIS is a valid, readily calculable predictor of mortality and morbidity in pediatric critical care. Population-specific thresholds and integration with multi-organ dysfunction scores enhance predictive utility. Future research should focus on prospective validation of thresholds and implementation of VIS-guided clinical decision support.

The Comprehensive Systematic Review of Fluid Overload and Mortality in Critically Ill Children Mohamad Fadli; Raka Jati Prasetya; Mutia Juliana
The Indonesian Journal of General Medicine Vol. 30 No. 1 (2026): The Indonesian Journal of General Medicine
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/bz9f0f42

Introduction: Fluid overload (FO) is a common complication in critically ill children associated with adverse outcomes. However, heterogeneity in definitions, measurements, and study populations has created gaps in understanding the true magnitude of this association. This systematic review aims to comprehensively synthesize evidence on the association between FO and mortality in critically ill children, examining definitions, measurement methods, and population-specific effects. Methods: A systematic review of observational studies, randomized controlled trials, and meta-analyses examining FO and mortality in critically ill children (0-18 years) admitted to PICUs, NICUs, or cardiac ICUs was conducted. Studies were screened based on predefined criteria including pediatric population, FO exposure with clear definition, mortality outcomes, and adequate sample size. Data extraction encompassed study characteristics, FO definitions, mortality outcomes, confounding adjustments, secondary morbidity outcomes, and methodological quality. Results: Sixty-five studies were included, comprising over 45,000 patients across general PICUs, cardiac ICUs, and specialized populations (sepsis, CRRT, ECMO, ARDS, TBI). FO definitions varied considerably, with percentage FO calculated as (fluid intake—output)/reference weight × 100 being most common. Thresholds ranged from ≥5% to ≥20%, with reference weights including admission, preoperative, or dry weight. Meta-analyses demonstrated significantly increased mortality with FO (pooled OR range: 4.34-5.06). A dose-response relationship was consistently observed, with 3-6% increased mortality odds per 1% FO increase. Mortality rates were consistently higher across FO thresholds: 29.4% vs. 65.6% for <10% vs. ≥20% FO in CRRT patients; 46% vs. 26% for >10% FO in sepsis. However, 4 studies found no independent association after multivariable adjustment. Secondary outcomes including prolonged mechanical ventilation, longer PICU/hospital stays, and AKI were consistently associated with FO. Discussion: This review demonstrates a consistent, dose-dependent association between FO and mortality across diverse pediatric critical care populations, though with important population-specific variations. The strongest associations were observed in sepsis, CRRT, ECMO, and post-cardiac surgery patients, while TBI showed inconsistent findings. The timing of FO assessment emerged as critical, with later-onset FO (>48-72 hours) showing stronger mortality associations. Methodological heterogeneity in FO definitions and measurement remains a significant limitation. Conclusion: Fluid overload is independently associated with increased mortality and morbidity in critically ill children, with evidence supporting a dose-response relationship. Standardized FO definitions and measurement protocols are urgently needed. Future research should focus on randomized trials of fluid management strategies and risk-stratified approaches.

The Comprehensive Systematic Review of Impact of Early Mobilization on Long-term Outcomes in ICU Patients Mohamad Fadli; Raka Jati Prasetya; Mutia Juliana
The International Journal of Medical Science and Health Research Vol. 32 No. 1 (2026): The International Journal of Medical Science and Health Research
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/7xkp5b59

Introduction: Early mobilization in intensive care unit (ICU) patients has been proposed to mitigate the deleterious effects of critical illness, yet its impact on long-term outcomes remains uncertain. This systematic review comprehensively evaluates the effects of early mobilization on long-term functional, cognitive, quality of life, and healthcare utilization outcomes in adult ICU patients. Methods: A systematic review was conducted following PRISMA guidelines. We included randomized controlled trials, controlled clinical trials, cohort studies, case-control studies, systematic reviews, and meta-analyses involving adult ICU patients (≥18 years) who received early mobilization (initiated within 72 hours of ICU admission or mechanical ventilation) compared to standard care or delayed mobilization. Long-term outcomes were defined as those measured at least 30 days post-ICU or hospital discharge. Data were extracted on patient characteristics, mobilization protocols, long-term outcomes, safety, and study quality. Results: Sixty-eight studies were included, comprising over 30,000 patients. Early mobilization consistently improved short-term functional outcomes, including muscle strength (mean difference 4.47-8.62 points on MRC scale), reduced ICU-acquired weakness (OR 2.04-2.7 for independent functional status), and increased likelihood of walking independently at discharge (OR 2.13) (Patel et al., 2023; Tipping et al., 2017; Hu et al., 2019). However, large randomized controlled trials found no significant improvement in long-term mortality (Hodgson et al., 2022) or quality of life at 6-12 months (Higgins et al., 2025). Notably, one trial demonstrated reduced cognitive impairment at 1 year (24% vs 43%, p=0.0043) (Patel et al., 2023). Subgroup analyses revealed potential harm in diabetic patients receiving high-intensity mobilization (adjusted OR 3.47 for 180-day mortality) (Serpa Neto et al., 2024). Adverse event rates were low (<3%), though the TEAM trial reported more events in the intervention group (9.2% vs 4.1%, p=0.005) (Hodgson et al., 2022). Discussion: The evidence presents a complex picture where early mobilization yields clear short-term functional benefits that do not consistently translate into improved long-term survival or quality of life. Heterogeneity in protocols, patient populations, and outcome measures limits definitive conclusions. Conclusion: Early mobilization safely improves in-hospital functional outcomes and reduces healthcare utilization. However, long-term benefits beyond hospital discharge remain unproven, and high-intensity protocols may harm specific subgroups. Individualized, progressive mobilization strategies are recommended.

A Comprehensive Systematic Review of The Role of Vasopressors in Early Management of Hemorrhagic Shock Mohamad Fadli; Raka Jati Prasetya; Mutia Juliana
The International Journal of Medical Science and Health Research Vol. 32 No. 1 (2026): The International Journal of Medical Science and Health Research
Publisher : International Medical Journal Corp. Ltd

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70070/wf2brc56

Introduction: The role of vasopressors in the early management of hemorrhagic shock remains controversial, with conflicting evidence from observational studies and randomized controlled trials. This systematic review aims to evaluate the efficacy and safety of early vasopressor administration in adult patients with hemorrhagic shock. Methods: A systematic review was conducted screening studies based on predefined criteria: adult patients with hemorrhagic shock from any cause, evaluation of any vasopressor agent within the first 24 hours, comparative study designs reporting clinically relevant outcomes. Fifty-eight sources were identified including randomized controlled trials, observational studies, and systematic reviews. Data were extracted on patient populations, vasopressor interventions, mortality outcomes, hemodynamic effects, fluid requirements, and adverse events. Results: Randomized controlled trials demonstrated that low-dose norepinephrine (<0.3 µg/kg/min) concurrent with fluid resuscitation significantly reduced 24-hour mortality (3% vs 13%, p<0.05) and in-hospital mortality (9% vs 21%, p<0.05) (Mohamed et al., 2024). The AVERT-Shock trial found no mortality difference with low-dose vasopressin but showed reduced blood product requirements (1.4 L vs 2.9 L, p=0.01) (Sims et al., 2019). Observational studies consistently associated vasopressor use with increased mortality (Aoki et al., 2018; Plurad et al., 2011; Fisher et al., 2020), though propensity-score analyses attenuated this association (Gauss et al., 2018). Vasopressors consistently achieved hemodynamic stabilization with improved mean arterial pressure and reduced fluid requirements. Adverse event profiles were similar between groups, with vasopressin associated with fewer deep venous thromboses (Sims et al., 2019). Discussion: The apparent contradiction between observational and randomized evidence is explained by confounding by indication, where sicker patients preferentially receive vasopressors. Context-dependent effects, agent-specific considerations, and timing of administration significantly influence outcomes. Low-dose vasopressors appear safe when used as adjuncts to—not replacements for—hemorrhage control and volume resuscitation. Conclusion: Early low-dose vasopressor administration, particularly norepinephrine and vasopressin, may be beneficial in selected patients with hemorrhagic shock, improving hemodynamic stability and reducing transfusion requirements without increasing mortality. Further research is needed to optimize agent selection, dosing strategies, and timing of initiation.

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